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FOOFFICE USE:- APPLICATION F OR SANITATION PERMIT Permit -------------------------------- { (Complete in Trplicate) Date issued - --------------- ------------ ---------= ---- This Permit Expires i Year From ate issued "f�=�- --�•OZ s� < #_ work herein cal ermit to construct and Application is hereby made to dean com Ilia o wiHh Counealth DtyrOrd Ordinance rict for a No. 5.49 and existing Rulestall theRegulations:gulat ons: described. This application is p W �� CENSUS TRACT -------------•------------ JOB ADDRESS/LOCATiO _Ti — /(f -------- ----- ------ / -----Phone------ ----OOwner's wner's Name _. �?� � C ------_--- -T Cit �----------- -ll�� ------------- Y Address ---- ------- � - -- - -- --- License �: -Q--- Phone -- A "------------------ Contractor's Name Installation will serve: Residence �partment House Commercial :❑Trailer Court 0 Motel ❑Other ---=--4-- ------------------------------•--- Number of living units:---L------- Number of bedrooms _.c7-------Garbage Grinder .- .--- Lot Size Private ----------- --- ------ ----- -- Water Supply: Public System an name -------------- Peat Sand Loam [� Clay Loam [ ' Silt[] Clay ❑ ❑ Y Character of soil to a depth of 3 feet: Sand'❑ Hardpan ❑ Adobe'❑ Fill Material ------------ if yes,type [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc- must be placed on reverse side.] NEW INSTALLATION: (No septic tank or seepa a pit permitted ;f ublic se -er ;s available within 200 feet,) !� ` i --i _ [� Size _ ��_�-�-�'-`�------- Liquid Dept h -- -- -------------------- PACKAGE TREATMENT [ ] SEPTIC TANK' jj �" � No. Compartments .-----•• p [ Capacity sacQ TYp Materia - °- s Foundation ./4'_ __._ ----- Prop. Line �� -----•-- Distance to nearest-. Well Q------------------- �y f Length of each line.__ p----------- ------ Total Len gthd ---•---- LEACHING LINE [tK No. of Lines _ ------------------ is .., fir T e F;Iter Material/Z--{-k------Depth. Filter Material V -------------------------------------- Foundation ------------------------- ----- 9 'D' BoxQ Foundation AQ Property Line-_2-e4r-- ----•----- D"istance to nearest: Well ---------- ------------------- SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number -------------------- ---- Water Table Depth -------------------- --------- -- Rock Filled Yes Q No 0�---- ------------------Rock Size ------------------------ - � Distance to nearest: Well ----------------------------_-----------Foundation ---- Prop, Line ----------••-------•-- Date ----------------------•-----------� - Li REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------ --------------- -------- -------- - a --------- ----------------- ------ ------ Septic Tank (Specify Requirements)'" `------ -------------------------------------- Disposal Field (Specify Requirements) --------------------------------------- ----------------------------------- ------------------------------------- } ------------------------------------------------------------ ------------- ------------ ------------------------------------------------------------------------------------------- ------ - (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, ! shall not employ any person in such manner I as to become subject to Workman's Compensation laws of California." --- - ---------------------- Owner Signed -- - -- - - - ------------------- - BY J (if other than owner) FOR DEPARTMENT USE ONLY ----� -�� ------------------------------- - ------- DATE --- �� rl f--------------------- APPLICATION..ACCEPTED BY -------"--- - ------DATE ------------- ----------------------------- BUILDING PERMIT ISSUED _---"-_--- _---- ------------------------------------------- ADDITIONAL COMMENTS ------ ------ ----------------- ------------------------- ---- -- --------------------------- ------- --- - --- - -------------------------------- ----- ---------------; -------- --------------------------- - - --------------------------------------- i - --- ------------------- ------ ---Date _f;1 - -- - ------- - ------------------------- --- ---- ------- ----------- Final Inspection by- ---- --- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 5 H 9 1-'6B Rev. 5M